What Doctors Feel

How Emotions Affect the Practice of Medicine

This highly acclaimed book examines how the quality of medical care is influenced by what doctors feel-the shame, fear, anger, anxiety, empathy, and even love that impact patient care.

Physicians are assumed to be objective, rational beings, easily able to detach as they guide patients and families through some of life’s most challenging moments. But doctors’ emotional responses to the life-and-death dramas of everyday practice have a profound impact on medical care. And while much has been written about the minds and methods of the medical professionals who save our lives, precious little has been said about their emotions. In What Doctors Feel, Dr. Danielle Ofri has taken on the task of dissecting the hidden emotional responses of doctors and how these directly influence patients.

How do the stresses of medical life—from paperwork to grueling hours to lawsuits to facing death—affect the medical care that doctors can offer their patients? Digging deep into the lives of doctors, Dr. Ofri examines the daunting range of emotions—shame, anger, empathy, frustration, hope, pride, occasionally despair, and sometimes even love—that permeate the contemporary doctor-patient connection. Drawing on scientific studies, including some surprising research, Dr. Ofri offers up an unflinching look at the impact of emotions on health care.

With her renowned eye for dramatic detail, Dr. Ofri takes us into the swirling heart of patient care, telling stories of caregivers caught up in and occasionally torn down by the whirlwind life of doctoring. She admits to the humiliation of an error that nearly killed one of her patients and her forever fear of making another. She mourns when a beloved patient is denied a heart transplant. She tells the riveting stories of an intern traumatized when she is forced to let a newborn die in her arms, and of a doctor whose daily glass of wine to handle the frustrations of the ER escalates into addiction. But doctors don’t only feel fear, grief, and frustration. Dr. Ofri also reveals that doctors tell bad jokes about “toxic sock syndrome,” cope through gallows humor, find hope in impossible situations, and surrender to ecstatic happiness when they triumph over illness. The stories here reveal the undeniable truth that emotions have a distinct effect on how doctors care for their patients. For both clinicians and patients, understanding what doctors feel can make all the difference in giving and getting the best medical care.

“Taut, vivid prose. . . . She writes for a lay audience with a practiced hand.” —New York Times

"Here is a book that is at once sad and joyful, frightening and thought-provoking. In her lucid and passionate explanations of the important role that emotions play in the practice of medicine and in healing and health, Danielle Ofri tells stories of great importance to both doctors and patients.” —Perri Klass, author of Treatment Kind and Fair: Letters to a Young Doctor

“An invaluable guide for doctors and patients on how to ‘recognize and navigate the emotional subtexts’ of the doctor-patient relationship.” —Kirkus Reviews

“Yet her insightful and invigorating book makes the case that it’s better for patients if a physician’s emotional compass-needle points in a positive direction.” —Booklist (starred review)

“Rich and deeply insightful. . . . A fascinating journey into the heart and mind of a physician struggling to do the best for her patients while navigating an imperfect health care system.” —Boston Globe

"Dr. Ofri's book is essential reading in Medical Humanities. She traces her own experiences with patients from all backgrounds, and uses clinical vignettes to confess her own feelings--disgust, fear, shame, gratitude, joy. She weaves together personal anecdotes and medical learning in a compelling account of her medical decisions and reflections. Highly recommended."—Sara van den Berg, Professor of English and Medical Humanities, Saint Louis University

"I have been a family physician for almost 50 years, and despite all those years of medicine, I was in tears about half the time while I read What Doctors Feel. I have recommended that every AHMA member read it."—Bill Manahan, Executive Director at Minnesota Holistic Medicine Group

"Dr. Ofri's anecdotal writing style makes this book a perfect accompaniment for the academic setting. Her real-life experiences can be incorporated into a variety of health science curricula bringing course theory together with practical application. As a result, her readers critical gain insight regarding why applying theory in the practice of medicine requires empathy for the physicians and proactive cooperation amongst colleagues."—Christine Whittrock, Associate Professor of Instruction in Regulatory Affairs, Temple University

"I describe patients to my students and ask them to role play either the doctor or the patient. I see a difference in their responses after they have read What Doctors Feel. They are more studied in their answers. Part of medical education now is not only core competencies from a factual standpoint but also a social standpoint. Dr. Ofri has a way of communicating those lessons in a clear a cogent and very personal fashion."—Beth Dollinger M.D. Arnot Ogden Medical Center

“What Doctors Feel is the perfect book for my research and teaching on the subject of lack of empathy in medical school students.”—James Asa Shield, Jr., MD, Professor, Chairman, Department of Psychiatry, Virginia Commonwealth University

“I certainly know your work—in fact, not only do I have copies of each of your books, but I often use your writing in my teaching at UNM medical school. I teach communication skills, ethics/professionalism, narrative medicine, and wellness, all under my role as Director of Physician and Student Wellness at the School of Medicine. I think the piece of yours I last used was ‘When Doctors Listen’ from the New York Times, and I just assigned What Doctors Feel in a course related to the Healer’s Art curriculum.”—Liz Lawrence, MD, FACP, Director, Physician and Student Wellness, Associate Professor, Department of Internal Medicine, UNM School of Medicine

Introduction

Why Doctors Act That Way

The experiences of medical training and the hospital world have been extensively documented in books, television, and film. Some of this has been probing and incisive, and some has been entertaining nonsense.

Much has been written about what doctors do and how they frame their thoughts. But the emotional side of medicine--the parts that are less rational, less amenable to systematic intervention--has not been examined as thoroughly, yet it may be at least as important.

The public remains both fascinated and anxious about the medical world--a world with which everyone must eventually interact. Within this fascination is a frustration that the health-care system does not function as ideally as people would like. Despite societal pressures, legislative reforms, and legal wrangling, doctors don’t always live up to these ideals. I hope to delve beneath the cerebral side of medicine to see what actually makes MDs tick.

One might reasonably say, I don’t give a damn how my doctor feels as long as she gets me better. In straightforward medical cases, this line of thinking is probably valid. Doctors who are angry, nervous, jealous, burned out, terrified, or ashamed can usually still treat bronchitis or ankle sprains competently.

The problems arise when clinical situations are convoluted, unyielding, or overlaid with unexpected complications, medical errors, or psychological components. This is where factors other than clinical competency come into play.

At this juncture in our society’s history, nearly every patient--at least those in the developed world--can have access to the same fund of medical knowledge that doctors work from. Anyone can search WebMD for basic information or PubMed for the latest research. Medical textbooks and journals are available online. The relevant issue-- the one that has the practical impact on the patient--is how doctors use that knowledge.

There has been a steady stream of research into how doctors think. In his insightful and practically titled book How Doctors Think, Jerome Groopman explored the various styles and strategies that doctors use to guide diagnosis and treatment, pointing out the flaws and strengths along the way. He studied the cognitive processes that doctors use and observed that emotions can strongly influence these thought patterns, sometimes in ways that gravely damage our patients. “Most [medical] errors are mistakes in thinking,” Groopman writes. “And part of what causes these cognitive errors is our inner feelings, feelings we do not readily admit to and often don’t even recognize.”1

Research bears this out. Positive emotions tend to be associated with a more global view of a situation (“the forest”) and more flexibility in problem solving. Negative emotions tend to diminish the importance of the bigger picture in favor of the smaller details (“the trees”). In cognitive psychology studies, subjects with negative emotions are more prone to anchoring bias--that is, latching on to a single detail at the expense of others. Anchoring bias is a potent source of diagnostic error, causing doctors to stick with an initial impression and avoid considering conflicting data. Subjects with positive emotions are also prone to bias; they are more likely to succumb to attribution bias. In medicine, this is the tendency to attribute a disease to who the patient is (a drug user, say) rather than what the situation is (exposure to bacteria, for example).

This is not to say that positive emotions are better or worse than negative emotions--both are part of the normal human spectrum. But if you consider the range of cognitive territory that doctors traverse with their patients--genetic testing, ordinary screenings, invasive procedures, ICU monitoring, and end-of-life decisions--you can appreciate how the final outcomes can be strongly influenced by a doctor’s emotional state.

Neuroscientist Antonio Damasio describes emotions as the “continuous musical line of our minds, the unstoppable humming.”3 This basso continuo thrums along while doctors make a steady stream of conscious medical decisions. How this underlying bass line affects our actions as doctors--and the net effect on our patients (and on doctors when we ourselves become patients!)--is what intrigues me.

By now, even the most hard-core, old-school doctors recognize that emotions are present in medicine at every level, but typically this is lumped in with the catch-all of stress or fatigue, with the unspoken assumption that with enough self-discipline, physicians can corral and master these irritants.

The emotional layers in medicine, however, are far more nuanced and pervasive than we may like to believe. In fact, they can often be the dominant players in medical decision-making, handily overshadowing evidenced-based medicine, clinical algorithms, quality control measures, even medical experience. And this can occur without anyone’s conscious awareness.

It could easily be argued that doctors are no more emotionally complex than accountants, plumbers, or the cable-repair guy, but the net result of doctors’ behavior--logical, emotional, irrational, or otherwise-- can have life-and-death consequences for patients, which is to say, for all of us.

We all want excellent medical care for ourselves and our families, and we’d like to assume that the best care comes from the doctors with the best training, or the most experience, or the best U.S. News & World Report rating. However, the myriad effects of emotional underpinnings can confound all of these factors.

Despite this, the conventional stereotype that doctors are fairly emotionless continues to maintain its hold. Many trace this back to the eminent Canadian physician Sir William Osler, often considered the father of modern medicine for such revolutionary ideas as whisking medical students out of the staid classroom and bringing them to the bedside to learn medicine by examining actual patients. The current educational system of clinical clerkships and residency training is largely attributed to Osler, as are hundreds of snappy quotations. His continuing influence is apparent in the scores of diseases, endless libraries, and numerous medical buildings, hospital wings, societies, and awards that bear his name.

On May 1, 1889, Dr. Osler stood before the graduating medical class at the University of Pennsylvania and delivered a valedictory-- and now canonical--speech entitled “Aequanimitas.”4 He stressed to these fledgling doctors that “a certain measure of insensibility is not only an advantage, but a positive necessity in the exercise of a calm judgment.”

While Osler may not have created these attitudes, he neatly encapsulated the general feeling about how doctors should behave.

Though he did warn against “hardening the human heart,” the stereotype of the detached, coolheaded physician springs from this idea of equanimity.

Popular culture has embodied this. Television doctors from Ben Casey to Gregory House are detached from their patients, lauded for their technological and diagnostic acumen. Even the selflessly idealist doctors (in Arrowsmith, Middlemarch, and Cutting for Stone) and the bitingly sarcastic doctors (in M*A*S*H, House of God, and Scrubs) maintain an equanimitous distance from their patients.

Every hospital dutifully includes the word compassion somewhere in its mission statement. Every medical school rhapsodizes about the ideals of caring. But the often unspoken (and sometimes spoken) message in the real-life trenches of medical training is that doctors shouldn’t get too emotionally involved with their patients. Emotions cloud judgment, students are told. Any component of a curriculum upon which interns slap the “touchy-feely” label is doomed in terms of attendance. Hyperefficient, technically savvy medical care is still prized over all else.

But no matter how it’s portrayed, and no matter how many high-tech tools enter the picture, the doctor-patient interaction is still primarily a human one. And when humans connect, emotions by necessity weave an underlying network. The most distant, aloof doctor is subject to the same flood of emotions as the most touchy-feely one. Emotions are in the air just as oxygen is. But how we doctors choose--or choose not--to notice and process these emotions varies greatly. And it is the patient at the other end of the relationship who is affected most by this variability.

This book is intended to shed light on the vast emotional vocabulary of medicine and how it affects the practice of medicine at all levels. Hopefully, the next time we find ourselves in a patient gown, we’ll better understand the workings of those who care for us. “Cognition and emotion are inseparable,” Groopman observes. “The two mix in every encounter with every patient.” In some scenarios, this mix is highly beneficial to patients. In others, it can be calamitous.

Understanding the positive and negative influence of emotions in the doctor-patient interaction is a crucial element in maximizing the quality of medical care. Every patient deserves the best possible care that doctors can offer. Learning to recognize and navigate the emotional subtexts is a critical tool on both sides of the exam table.

From the Hardcover edition.

Intoduction: Why Doctors Act That Way

Chapter 1: The Doctor Can't See You NowJulia, part one Chapter 2: We Build a Better Doctor?Julia, part twoChapter 3: Scared WitlessJulia, part threeChapter 4: A Daily Dose of DeathJulia, part fourChapter 5: Burning with ShameJulia, part fiveChapter 6: DrowningJulia, part sixChapter 7: Under the Microscope Julia, part seven

Click here to read a piece by Ofri on immigration and healthcare on TheAtlantic.com

Click here to listen to the author's guest appearance on Radio Times/WHYY Radio (Philly NPR)

Click here to read a review by Clinical Correlations: The NYU Langone Online Journal of Medicine

Click here to watch and interview with Danielle on the BBC Health Check's website

Danielle Ofri wrote "Adventures in 'Prior Authorization,'" an op-ed for the New York Times about insurance companies attempting to prod doctors away from expensive treatments and toward less expensive alternatives, 8/3/14

Contents

About the Book

In this book of real-life stories intermixed with the latest research, Dr. Danielle Ofri examines the often overlooked aspect of medicine—how doctors feel. By shedding light on how doctors cope with the stresses and responsibilities of patients, colleagues, lawyers, and their personal lives, she explains why it is important that patients know how emotions influence the way physicians treat their patients both medically and interpersonally. Exploring the full range of human emotion—from the fear of making a fatal mistake to the pride and elation of triumphing over death, What Doctors Feel allows patients at the other end of the stethoscope to have a good listen to the beat of the emotional life behind the white coat.

Praise

“The world of patient and doctor exists in a special sacred space. Danielle Ofri brings us into that place where science and the soul meet. Her vivid and moving prose enriches the mind and turns
the heart.” —Jerome Groopman, author of How Doctors Think

“Danielle Ofri is a finely gifted writer, a born storyteller as well as a born physician.” —Oliver Sacks, author of Awakenings

“Danielle Ofri … is dogged, perceptive, unafraid, and willing to probe her own motives, as well as those of others. This is what it takes for a good physician to arrive at the truth, and these same qualities make her an essayist of the first order.” —Abraham Verghese, author of Cutting for Stone

“Her writing tumbles forth with color and emotion. She demonstrates an ear for dialogue, a humility about the limits of her medical training, and an extraordinary capacity to be touched by human suffering.” —Jan Gardner, Boston Globe

“Here is a book that is at once sad and joyful, frightening and thought-provoking. In her lucid and passionate explanations of the important role that emotions play in the practice of medicine and in healing and health, Danielle Ofri tells stories of great importance to both doctors and patients.” —Perri Klass, author of Treatment Kind and Fair: Letters to a Young Doctor

“An invaluable guide for doctors and patients on how to 'recognize and navigate the emotional subtexts' of the doctor-patient relationship.”—Kirkus Reviews

“Ofri’s passionate examination of her own fears and doubts alongside broader concerns within the medical field should be eye-opening for the public—and required reading for medical students.”—Publishers Weekly

About the Author

Danielle Ofri MD, PhD is an associate professor of medicine at New York University and has been caring for patients at Bellevue Hospital, the oldest public hospital in the country, for over two decades. She is editor-in-chief and cofounder of the Bellevue Literary Review, the first literary journal to arise from a medical setting. She is the author of three collections of essays about life in medicine: Singular Intimacies, Incidental Findings, and Medicine in Translation. This is her fourth book.

Dr. Ofri’s essays have been published in the New York Times, the Los Angeles Times, the Washington Post, on NPR, and in numerous medical and literary journals and anthologies, among them the New England Journal of Medicine, Best American Essays, and Best American Science Writing. She is a frequent contributor to the New York Times’ “WellBlog” and the New York Times’ science section. She received the John McGovern Award from the American Medical Writers Association for “preeminent contributions to medical communication.” Dr. Ofri edited the anthology The Best of the Bellevue Literary Review and was also editor of the award-winning medical textbook, The Bellevue Guide to Outpatient Medicine. She lives with her husband, three children, cello, and black-lab mutt in a singularly intimate Manhattan-sized apartment.

Questions for Discussion

Introduction

Do you think patients need to know about doctors’ emotions? Have you ever had experiences with medical professionals whom you considered either too emotionally attached or too detached? If you are a doctor or medical student, have you ever struggled with different approaches to handling emotion?

The divide between reason and emotion is a longstanding concept in western thought. Do you think rationality and emotion are mutually exclusive, or is this a false dichotomy? Why do you think doctors in particular are assumed to be more rational than emotional?

Dr. Ofri cites Sir William Osler and his canonical speech “Aequanimitas” which stresses that “a certain measure of insensibility is not only an advantage, but a positive necessity in the face of calm judgment.” How do you think Osler’s opinion has impacted medical practice and popular perception of doctors? How is insensibility or being detached as a doctor an advantage? How is it a disadvantage?

Ofri writes that there is essentially no such thing as a doctor with no emotion, just doctors who choose or choose not to (in varying degrees) process emotions. Do you agree? Why?

“I knew that I had to swallow it all back, that I had to continue my approach toward this woman. This is what I’d signed on to when I enrolled in medical school—to help patients in need, no matter who they were or what they looked like. The Hippocratic Oath, the Oath of Maimonides—this was what these professional oaths were written for.” (p. 7)

On Ofri’s first call as a volunteer rape crisis counselor, her patient is a homeless woman whose smell and appearance repel Ofri so much that she is unable to approach the woman and treat her. What does this incident illustrate about compassion in general? How is compassion in everyday interactions different than it is in a healthcare setting? Have you ever had a similar experience of feeling unnerved in someone’s presence?

Ofri writes that empathy is easier when we have common ground with the other person. What challenges does this create when dealing with people with diverse backgrounds and life experiences?

Ofri mentions a patient who exaggerates all of her symptoms. How can differences of perspective and experience make patients and doctors disagree about diseases and treatments?

Ofri mentions that some medical professionals express contempt for patients with conditions they consider at least partly self-inflicted, such as obesity or addiction. Does our society in general stigmatize these conditions? Do we consider any problems to be social issues that are in fact primarily medical issues, or vice versa? How does this affect people seeking treatment for these issues?

How is uncovering a patient’s personal history (not just his or her medical history) valuable to the healing process for both doctor and patient?

Julia, part one

“We doctors were in an emotional bind. The rational doctor side of us knew exactly what facts to convey to her. But the emotional, human side of us could not bring ourselves to be the conveyers of this horrible twist of fate. To have a potential cure for your patient and then to have to tell your patient that she can’t get it and will thus die places a human being in an emotionally untenable spot.” (p. 25)

Dr. Ofri explains that when Julia was first diagnosed with congestive heart failure, both Ofri and her colleagues were unable to deliver Julia the bad news. Why might doctors hesitate to give patients a terminal diagnosis? Was it wrong not to tell Julia the whole truth upfront? Why?

Chapter Two: Can We Build a Better Doctor?Themes: Loss of Empathy, Teaching/Preserving Empathy, the “Hidden Curriculum” of Medical School

"The students' true teachers are no longer the august, gray-haired professors who practiced medicine in "the days of the giants" but harried interns and residents in grubby white coats stained with the badges of medicine in the trenches." (p. 33)

Ofri opens this chapter by pondering whether empathy is innate or learned. Do you think empathy is an inherent trait, learned, or a combination of both? Can empathy be taught, and if so, how?

Ofri notes that the classroom years of medical school are vastly different from the clinical years. Not only are the classroom years more uniform but “everything existed for [students’] sake. Their medical education was the raison-d’être of the entire enterprise” (31). The clinical years, by contrast, are chaotic and often dismantle the students’ idealistic views of medicine. How do the first experiences with real patient care demoralize medical students? Do other professions experience a similar discrepancy between education and work experience, or is medicine unique in this respect?

What does Ofri mean by the “hidden curriculum” of medical school?

This chapter shows that humor can be used to help doctors cope with stress, but gallows humor can also desensitize doctors. Can humor help people cope with dire situations, or does it always trivialize them? How can a doctor’s explanations and word choice affect your experience as a patient? When you are in a patient role, do you prefer that doctors use their usual medical jargon or that they simplify their language instead? How does the use of medical jargon or simplified language affect your patient experience?

Julia, part two

How does Julia's status as an undocumented immigrant complicate her medical care? Can you think of other groups of people who often fall through the cracks or are ignored in our health care system?

The resiliency of Julia’s body and spirit gives Ofri hope despite knowledge that there is little that can be done. Have you ever latched onto hope despite odds that seem stacked against you? Was it helpful or detrimental?

Do you think it was right for Ofri, as a doctor, to favor hope over reality? Does the goal of thinking rationally about survival odds deprive patients of hope?

Chapter Three: Sacred Witless
Themes: Fear, Stress

“This fear of making a mistake and causing harm never goes away, even with decades of experience. It may be most palpable and expressible in neophyte students and interns, but that is the merely the first bead in a chain that wends its way throughout the life of a doctor. It may be sublimated at times, it may wax and wane, but the fear of harming your patients never departs; it is inextricably linked to the practice of medicine.” (p. 68)

In academic and work settings, many people thrive on stress and adrenaline. Do you find that stress makes you more or less productive? If your reaction to stress is unpredictable, how could this affect your job performance and your well-being?

Medicine is one of the rare professions in which fears constantly revolve around death or endangerment. How do some of your fears help or hinder your daily life both privately and professionally?

How can fear be healthy for both doctors and patients? Does fear humanize doctors, or does it make them seem incompetent? Does it bring out arrogance?

One of Ofri’s overriding fears is letting something slip under the radar or missing a rare disease amidst everyday aches and pains. Medicine is a profession with a high level of accountability and potential for deadly error. Are there any other fields that have a similar level of responsibility? How does the high risk of error contribute to certain stereotypes about these professionals—for example, that they’re perfectionists or arrogant? Are these stereotypes, in fact, reasonable? Do we have even more specific stereotypes about different types of healthcare professionals?

Chapter Four: Daily Dose of DeathThemes: Grief, Sorrow, PTSD

“Eva was suddenly consumed with a wave of immense sadness for this tiny baby, this little girl. To never have been held by her parents, to never have been held by anyone. It was almost beyond comprehension.” (p. 101–102)

Before reading this book, how did you imagine doctors dealt with observing suffering and death?

Ofri describes some of the experiences that Eva, a pediatrician, had during her pediatrics internship. One of the most traumatic experiences was waiting for a baby with Potter’s syndrome to die so that she could record time of death. Why might many medical residents repress their traumatic experiences? How does Eva’s desire to avoid her feelings about this incident impact her patient care and the families of her patients?

Can people actually compartmentalize sadness? Are there benefits to this? What negative effects does it have? How might the way a doctor deals or does not deal with grief directly impact patient care?

Ofri argues that a crucial aspect of navigating grief is to acknowledge it. Everyone has experienced grief for a loved one, but have you ever been sad over the death of a stranger? How is the doctor/patient relationship different from either of those categories?

Eva’s early experiences with grief in the NICU impressed upon her the importance of the emotional well-being of her patients and their families. This leads her to refrain from diagnosing Down syndrome in one of her patients shortly after birth in order to give the parents time to bond with their newborn. Is it ever OK to withhold information or a diagnosis, and if so, when? How is withholding the suspicion of a disability different than hesitating to give a life-threatening diagnosis, as Ofri did with Julia?

In describing her grief over the death of Mr. Edwards, Ofri compares grief to love, writing that the human capacity to grieve can expand just like its capacity to love. Though she does not welcome sadness, she knows that “the connections that permit grief to occur are the connections that keep us—doctors and patients—alive.” Ofri writes that what matters most with regards to grief is how it is handled and addressed. What do you think is the happy medium between acknowledging the importance of human connections and not allowing oneself to be consumed by sadness and grief?

Julia, part four

“It was like I’d had a long-term relationship with the healthy, robust Julia, the one who wasn’t going to die, and like any creature of habit, I wasn’t prepared for when the relationship changed. But as the months wore on, I could no longer delude myself. That healthy Julia was fading before my eyes, aging and weakening in real time.” (p. 122)

Ofri notes that Julia’s “web of connections” comforted her. How are active support systems helpful and necessary to patient health?

Despite the slow but obvious decline in Julia’s health, Ofri refuses to welcome or “jumpstart” her grief. Is it possible to shut out grief completely? What are the consequences? Have you ever wanted to shut out grief completely?

“But it was the shame that was paralyzing. It was the shame of realizing that I was not who I thought I was, that I was not who I’d been telling my patient and my intern I was. It wasn’t that I was forgetful or momentarily distracted. It was not that I was neglectful or even uncaring. It was that up until that moment, I’d thought I was a competent, even excellent, doctor. In one crashing moment of realization, that persona shattered to bits.” (p. 129)

Ofri describes how soon after completing her internship, she nearly killed a patient by not ordering long-acting insulin in a patient with DKA (diabetic ketoacidosis). In this incident, her attempts to think logically actually harm the patient. Have you ever “over-thought” a situation, with detrimental results? Did it change the way that you approached similar situations in the future?

Ofri describes her reticence to apologize to patients and their families. How are doctors’ apologies different than those in ordinary interactions? Do we see doctors as infallible?

Ofri notes that perfectionism in medicine creates the idea that “you’re either an excellent doctor or a failure” (129). What is the fall-out of this construct? Is this “all-or-nothing” attitude unique to medicine, or do we see it elsewhere?

Ofri cites a study about medical error which showed that students who discussed their errors and admitted responsibility were more likely to have made constructive changes in their behavior than those who never discussed their error. How can doctors learn and benefit from past mistakes? Why would the medical community try to downplay errors?

If you were a patient and there was a near-miss error (an error that occurred but didn’t actually cause you harm) would you want to know about it? What are the positives and the negatives about being made aware of a near-miss error? Do you consider a near-miss error to be malpractice?

“Disillusionment can be a pervasive state of being, calling up a complex of emotions triggered by feeling that medicine wasn’t what you thought it was, that your ideals of being a doctor have come into conflict with reality, and that reality is flattening those ideals to the mat.” (p. 149-50)

Although Joanne initially loves working in the ER, she grows to hate it, finding herself endlessly frustrated with patients who won’t take care of themselves. In combination with the stress of being a single mother, Joanne’s disillusionment with medicine drives her to drink. What other ways, aside from alcoholism, might a doctor’s disillusionment manifest and affect his or her patients?

What factors might cause doctors to become alcoholics or have other addictions? Do you think doctors’ knowledge and observation of others’ addictions make their own addictions more surprising?

This chapter describes the transition between student-centered medical school and a patient-centered work environment, and how many doctors’ skills reach a plateau. How do people in other jobs experience this tension between improving oneself and helping others? Is it possible to do both equally well, or do people focus on one or the other? Knowing that every hour a doctor takes herself away from medicine is one hour less for patients, do you think there is an element of selfishness in doctors taking time to enhance their own lives?

Julia, part five

“After eight frightening years with Julia’s life on the line, people had finally listened. The world had finally listened. It had opened its heart and given her a second chance at life.” (p. 172)

Ofri writes that “tears of joy might rank as one of the most sublime experiences in the emotional vocabulary” and that joy is “a rare commodity in medicine. So rare that it hardly merits mention.” If joy is so rare, why do you think that doctors stay in medicine, knowing they will see so little of it?

Upon hearing that Julia would receive a heart, Ofri is eager to contact a vast network of friends to let them know the good news. The incredible number of people in Ofri’s network who have followed Julia’s health is, in and of itself, a testament to how emotionally involved Ofri has become over the course of their doctor-patient relationship. Is this too much? Has she compromised her ability to be objective? Has she harmed her patient in any way? Do you think it is wise for doctors to become emotionally invested with patients?

Chapter Seven: Under the MicroscopeThemes: Judgment, Lawsuits

“I felt like I’d just stripped naked in front of the Inquisition, then dismissed with nothing more than a vague, non-committal wave-of-the-hand.” (p. 178)

Ofri describes a chart review she had with a hospital lawyer for a potential lawsuit concerning a patient named Mercedes. The session reveals no mistakes on Ofri’s part, but it leaves her with an “embarrassing, inconclusive, foreboding” feeling. If no mistakes were found, why does she feel so awful?

Ofri describes the experience of Sara Charles, a psychiatrist, who was sued by the family of a former patient who attempted to commit suicide; the family blamed Sara even though Sara felt she had done all she could and more for her patient. Did you think Sara was at fault?

On balance, do you think that lawsuits do more harm or do more good in our society? Has anyone you know ever sued a doctor, or been sued by a patient?

Defensive medicine, such as the over-ordering of tests and treatments, is one of the most common reactions by doctors to lawsuits. Does this knowledge change how you would feel, as a patient, when your doctor orders a test?

The quality measures movement is intended to offer hard data to allow patients and hospitals to judge the quality of doctors. Why do you think doctors are uncomfortable about being judged by this type of data? Is that a reasonable response? What do you think about online patient reviews of doctors? How have you selected a doctor when you’ve needed one? What measures would you find useful and meaningful in selecting a doctor?

Julia, part six

“Despite the hardships of her life, Julia had maintained an uncanny tenderness, enduring but also prospering, savoring a life filled with love. Her human spirit had indeed been well spent.” (p. 209)

Now that you’ve finished reading the book, why do you think Danielle Ofri chose to weave in the story of Julia throughout?

Throughout the book Ofri embraces all the emotions felt during her time as Julia’s doctor (and friend). Do you think that Ofri’s emotions had a positive impact on Julia’s life and care, or do you think there might have been negatives? Did you get a sense of Julia’s thoughts and feelings from the book?

In a novel, Julia’s story might have ended with the heart transplant (and a successful one at that). Did her death make her seem more or less real? Did her death erase any of the more positive emotions that you may have felt throughout the story?

Ofri’s as-they-happen snapshots allow the reader to fully connect with both Ofri and Julia. Did the story-telling technique make you feel the emotions more intensely? Did it give you any sense of the benefits (and detriments) of doctors connecting emotionally with patients?

Afterword

What encompasses caring for a patient? Do you think the book has shown in what ways (aside from medical treatment) that doctors care for their patients?

Do you feel that a doctor’s attunement to both her own and her patients’ emotions is crucial to the healing process? Are there downsides?

Does the book suggest ways to balance emotion with rationality? Can optimism be detrimental to patients? If so, how? What about love?